Hemolytic anemia differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2]
Overview
Differentiating Hemolytic anemia from other Diseases
| Characteristic/Parameter | Hemolytic anemia | Sideroblastic anemia | Anemia of chronic disease | Thalassemia | Iron-deficiency anemia | Erythropoietin deficiency | Vitamin B12 or folate deficiency |
|---|---|---|---|---|---|---|---|
| Etiology | Drug-induced, immune-mediated, non-immune-mediated, infections, rheumatologic disease | Alcoholism, lead poisoning, vitamin B6 deficiency, isoniazid, chloramphenicol | Chronic kidney disease, rheumatologic disease, cancer, HIV, chronic infection; excess release of IL-1 and IL-6 | Genetic defect with alpha- or beta-globin production | Loss of iron from gastrointestinal blood loss or menstrual blood loss | Chronic kidney disease or other renal dysfunction | Bleeding, photosensitivity, arthritis, malar rash, discoid rash, renal failure, seizures, psychosis |
| Mean corpuscular volume | Normocytic (80-100 femtoliter) | Microcytic (<80 femtoliter) or normocytic (80-100 femtoliter) | Normocytic (80-100 femtoliter) | Microcytic (<80 femtoliter) | Microcytic (<80 femtoliter) | Normocytic (80-100 femtoliter) | Variable; usually low |
| Laboratory abnormalities | Indirect hyperbilirubinemia, reticulocytosis, low haptoglobin, elevated LDH | Ringed sideroblasts in bone marrow; low vitamin B6 level, high lead level | Elevated ESR and CRP, elevated hepcidin, low serum iron, low transferrin, elevated ferritin | Abnormal hemoglobin electrophoresis (in beta-thalassemia) | Low serum iron, elevated transferrin, low transferrin saturation, low ferritin | Low erythropoietin level | Usually normal |
| Physical exam | Pallor, jaundice | Pallor, weakness | Pallor, weakness | Irritability, growth retardation, jaundice, hepatomegaly, splenomegaly | Pallor, weakness, positive occult blood testing (if GI bleeding) | Pallor, weakness, signs of chronic kidney disease | Autoimmunity with development of antibodies to DNA |
| Treatment | Removal of offending agent, steroids, alternative immunosuppression | Removal of offending medication, high-dose vitamin B6 (up to 200mg daily), avoidance of splenectomy, symptomatic transfusion support with iron chelation as needed | Treatment of the underlying cause; erythropoiesis-stimulating agents, supportive red blood cell transfusions | Transfusion support, iron chelation, gene therapy if available | Intravenous or oral iron supplementation | Epoetin alfa 50-100 units/kg 3 times weekly, darbepoietin 0.45 mcg/kg weekly or 0.75 mcg/kg every 2 weeks | Possible; drug-induced lupus can be caused by medications like hydralazine or isoniazid |
| Other associated abnormalities | HELLP syndrome, TTP, CLL | Myelodysplastic syndrome, myeloproliferative neoplasm, iron overload | Inflammatory bowel disease | Extramedullary hematopoiesis | Chronic blood loss | Dialysis dependence, myelodysplastic syndrome | Rare |